Utilization Review in Illinois (attorney presentation)
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1 Utilization Review in Illinois (attorney presentation) Presented by: Mary Ellen Kozeluh,, UR Manager Jennifer Weber, UR Supervisor August,
2 Overview Utilization Review - history State of Illinois requirements of URO URAC Standards Types of Review / URAC Process/Timeframes Guidelines Evidence-based Medicine Arbitrator Feedback Review UR determinations closely Request Attorney Packet from UR CorVel contact information 2
3 Utilization review is NOT new Medicare Medicaid HMO plans PPO plans Slowly states have begun to adopt this practice for workers compensation cases 3
4 Abuses Why was UR instituted? Overuse of testing Inappropriate testing for diagnosis Inappropriate hospital stays Lengthy hospital stays Medical studies that physicians rely on have always been around to help physicians specialty organizations decide on treatment 4
5 State of Illinois Requires companies who perform UR UROs are required to follow the URAC standards sufficient to achieve URAC accreditation (820 ILCS 305/8/7) Nothing in this Act shall be construed to require an employer or insurer or its subcontractors to become URAC accredited. (820 ILCS 305/87) Must register and apply for certification with the State of IL every 2 years. 5
6 URAC and its Standards (WCUM) Protector of the Utilization Process Originally URAC was incorporated under the name Utilization Review Accreditation Commission the name was shortened to just the acronym URAC Accreditation serves as a symbol of excellence in the health care industry The standards apply to the utilization management process when it occurs in a workers compensation setting There are CORE Standards and WCUM standards - primary element has direct & significant impact on the welfare and safety of consumers/patients. The secondary element is desirable of a high quality program but does not have a direct impact on welfare and safety of consumers 6
7 Utilization Review Types Process 7
8 Types of Utilization Review Prospective reviews (pre-certs certs) Concurrent reviews (ongoing treatment) Retrospective reviews (treatment has been rendered) 8
9 UR Process Initial review: The nurse receives the request for review and medical records If additional records are required, the nurse can contact the provider Nurse reviews the medical records and the treatment under review Applies to ODG guidelines Certifies if treatment is appropriate Informs the provider by phone of the certification Sends certification letters to provider, injured employee, attorney, adjuster If the treatment does not meet guidelines 9
10 UR Process when guidelines not met The UR nurse refers to Clinical Peer Reviewer Utilizing evidence based medicine and nationally recognized guidelines, the Clinical Peer Reviewer (medical doctor) reviews & provides a UR determination Based on Peer decision, the Certification or Non- Certification Letters are sent to all parties Appeal process and peer report are sent with all non-certifications 10
11 Clinical Peer Reviewer Licensed doctor of medicine or doctor of osteopathic medicine or Licensed health professional in the same licensure category as the ordering provider or Health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued. 11
12 Peer-to-Peer Conversations Clinical Peer must be available to discuss review determinations with the treating provider Requested by treating provider Purpose: allows treating provider a chance to discuss a UM determination before the initiation of the appeal process. (hopefully avoiding need for formal and adversarial appeal process) 12
13 30 days to Appeal Appeal process UR Organization receives appeal request via fax or phone - can be made by treating provider, injured employee, attorney Sent to Clinical Peer Reviewer w/ any addl medical info Nurse sends out Cert or Non-Cert Ltr based on Peer determination 2 types of appeals: expedited and standard Right to standard appeal, if utilized expedited 13
14 Clinical Peer Reviewer for Appeals Hold an active, unrestricted license to practice medicine or a health profession Must be Board-certified Are in the same profession and in a similar specialty as typically manages the medical condition Are neither the individual who made the original non-certification, nor the subordinate of such individual 14
15 Administrative Non-Cert For lack of medical records UR calls provider requesting records Calls 2 nd day requesting same 3 rd day sends out Non-Cert for Lack of Medical Records Once records received UR process continued 15
16 Guidelines utilized by Nurses and Peer Physicians Nationally recognized ODG, ACOEM, Milliman-Roberts, Interqual Best practice, evidence-based medicine Evidence-based recommendations are based on valid scientific outcomes research, preferably research that has been published in peer reviewed scientific journals. Evidence-based information can be used to develop protocols, pathways, standards of care or clinical practice guidelines and related educational materials ODG updated regularly at 3 month, 6 month or yearly episodes 16
17 Physicians utilize evidence-based medicine what is evidence-based medicine? The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Physicians arrive at medical decisions by relying on standards of care and individual clinical experience: Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients. 17
18 Timeframes to Complete UR Review Per URAC: Prospective Review: Initial review 72 for Urgent Care* 15 calendar days for Non-Urgent Care Concurrent Review: Initial Review 24 hours for Urgent Care* 15 calendar days for Non-Urgent Care. Retrospective Review: - Within 30 Calendar Days (May be Extended 15 days if Necessary) Appeal timeframes: Expedited: completed with verbal notification within 72 hrs of the request, followed by written confirmation within 3 calendar days Standard: completed with written notification within 30 calendar days from receipt of request for appeal CorVel Timeframes: Prospective Review: 3-5 days Concurrent Review: 3-5 days Retrospective Review: dependent on volume of records; number of treatments being reviewed anywhere from days Appeals: Expedited: as per URAC Standard: within 30 days; rushed 10 days dependent on volume 18
19 How is the Treating provider contacted? Notified by phone Followed up with a letter of certification Non-certification letters include the Appeals Process and Peer Report 19
20 Arbitrator Feedback - Comments Arbitrators comments: Litigator s tool just delays treatment Out-of-state Peers not local medicine Credibility of Peer Physician CVs are important UR 4 p.t. visits not appropriate Guidelines cookbook medicine; developed by who? Occ med? Peer Physician occ med reviewing Specialist (Ortho( Ortho) ) recommendations Disconnect between URO and Defense Attorneys Hearsay Response to Arbitrators: If UR performed appropriately and within appropriate timeframes with cooperation of treating provider it does not delay treatment Medicine is national / international physicians rely on same medical standards Need to send appropriately to UR Guidelines were developed by physicians, specialists based on standards of care Peer physicians should be specialty to specialty again appropriateness of reviewing company Attorneys require URO certification, CV of peer, peer report, non-cert letters, etc. Peer reports are now sent to treating providers helping to eliminate the complaint of hearsay 20
21 Review the UR determination closely Is the non-cert due to poor documentation of the treating provider? Is the non-cert for a minimal amount of p.t. visits? Did the URO have the correct medicals in order to process UR? MRIs are needed to review for appropriateness of surgery If there is a case manager on the case, ask the nurse to closely review the rationale for non-cert URO should have QA d d the peer report 21
22 Call CorVel UR to Request an Attorney Packet CorVel s State of IL certification URAC Accreditation certificate UR non-certification letter Peer Report Peer CV Appeal confirmation Appeal determination and Peer Report Peer CV Reports on Peer-to-Peer conversations 22
23 CorVel UR Contact and Referral information Jenny Weber, RN, UR Supervisor Phone: corvel.com Complete referral form in packet to corvel.com Questions for referral: call Kim Lindholm at
24 Questions? 24
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Office of Long-Term Living Individual Support Forum Place 555 Walnut Street Harrisburg, PA 17101
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1. Applicant Name: (Please check one) [ ]Insured/Patient [ ]Patient s Designee [ ]Provider. 2. Patient Name: 3. Patient Address:
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